Form Ds-870.1 - Article 19-A School District/other Contract Notice
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1DS-870.1 (11/17)
ARTICLE 19-A SCHOOL DISTRICT/OTHER CONTRACT NOTICE
NOTE: This form shall be submitted by a carrier anytime
a contract is added, dropped, or modified.
CARRIER INFORMATION
Carrier/DBA Name
Legal Name (if different)
Federal ID Number
19-A Business ID Number
Street Address
City
State
Zip Code
SCHOOL DISTRICT/OTHER CONTRACT INFORMATION
For EACH contract served, provide the following information. If you need more space to report contract information, you may photocopy this
page and attach the copies to this form.
o
o
o
Modify ⎯ Check ALL appropriate boxes to identify the type of institution/client groups served:
Add
Drop
o
o
o
o
o
Academic
Day Care
Mentally Disabled
Vocational
Nursery/Pre-School
o
o
o
o
Camp
Religious
Physically Disabled
Other (Specify)
Federal I.D. Number of Contract
Contract Name
Contract Period
Mailing Address (Include No. and Street)
City
State
Zip Code
County
Telephone Number (Area Code)
(
)
Name of Article 19-A
Title of Contact Person
Contact Person
o
o
Drop ⎯ Check ALL appropriate boxes to identify the type of institution/client groups served:
Add
o
o
o
o
o
Academic
Day Care
Mentally Disabled
Vocational
Nursery/Pre-School
o
o
o
o
Camp
Religious
Physically Disabled
Other (Specify)
Federal I.D. Number of Contract
Contract Name
Contract Period
Mailing Address (Include No. and Street)
City
State
Zip Code
County
Telephone Number (Area Code)
(
)
Name of Article 19-A
Title of Contact Person
Contact Person
o
o
Drop ⎯ Check ALL appropriate boxes to identify the type of institution/client groups served:
Add
o
o
o
o
o
Academic
Day Care
Mentally Disabled
Vocational
Nursery/Pre-School
o
o
o
o
Camp
Religious
Physically Disabled
Other (Specify) ________________________________
Federal I.D. Number of Contract
Contract Name
Contract Period
Mailing Address (Include No. and Street)
City
State
Zip Code
County
Telephone Number (Area Code)
(
)
Name of Article 19-A
Title of Contact Person
Contact Person
Signature of Carrier Representative
X
Date
Print Name:
Send original to New York State Department of Motor Vehicles, Bus Driver Unit; keep a copy in your files.
All questions pertaining to this form and/or the Article 19-A Program should be directed to: New York State Department of Motor Vehicles,
Bus Driver Unit, 6 Empire State Plaza, Room 136B, Albany, NY 12228, (518) 473-9455.
dmv.ny.gov
reset/clear
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